Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Stratford Villa Post-acute during CMS and state inspections, most recent first.
The facility failed to obtain and verify informed consent for brain mapping/neurofeedback treatment for two cognitively impaired residents receiving services from a third-party provider. The ADM reported that the provider was to secure consent from responsible parties and that the facility would verify this by placing a copy in the medical record, but no such consents were found in the charts. One responsible party stated they were unaware of the neurofeedback treatment, had not given consent, and had not had the procedure explained, despite facility policy requiring disclosure of material information, the opportunity to consent or refuse treatment or experimental research, and verification of informed consent by facility staff.
Two residents with Parkinson’s disease, dementia, and severe cognitive impairment received brain mapping/neurofeedback therapy ordered by an MD for altered mental status, with orders specifying QEEG brain mapping and multiple neurofeedback sessions followed by re-evaluation. A third-party provider delivered the therapy in the facility, and visit notes stated that the plan of care was coordinated with the primary care team and that staff were counseled on hydration and nutrition in conjunction with neurofeedback. However, the ADM and DSD/LVN acknowledged there were no nursing care plans addressing this therapy, no after-treatment care instructions were provided to nursing staff, and visit notes were not supplied promptly. One resident’s responsible party later requested that the therapy be stopped and reported they had not consented to the treatment.
A resident with severe cognitive impairment and an indwelling G-tube had orders and a care plan requiring Enhanced Barrier Precautions (EBP) during high-contact care, including device care. An LVN entered the room, performed a water flush via the G-tube, and helped reposition the resident in bed without donning a gown, despite EBP signage on the door and the facility’s policy requiring gown and glove use for high-contact activities involving feeding tubes.
The facility did not meet state requirements for a full-time RD or DS, with the DS working only 20 hours a week and the RD working 8-16 hours a week. This affected the food and nutrition services for all 26 residents.
The facility failed to store and prepare food in accordance with professional standards, including improper placement of a hand washing sink, opened food items with no use-by dates, and inadequate dishwashing practices. Additionally, the ice machine and kitchen vents were found to be unclean, and a dietary aide did not follow proper hand hygiene protocols.
The facility failed to ensure safe medication storage and accurate labeling. A resident's medication card for Colchicine did not match the physician's order, and three and one-half loose tablets were found in a medication cart. These issues posed risks for medication errors and contamination.
The facility failed to properly dispose of garbage and contain refuse when a dumpster was observed to be full of trash bags and not closed or covered. The Dietary Services Supervisor confirmed the dumpster should have been closed, and the Maintenance Director stated it should be closed when not in use. Facility policy requires the dumpster to be locked when not in use and at night.
The facility failed to include a resident and their representative in the development and implementation of the hospice plan of care. The resident's representative expressed concerns about the lack of communication regarding the resident's care, and the facility did not arrange a care planning conference as required by their policy and the hospice services agreement.
Failure to Obtain and Verify Informed Consent for Neurofeedback Treatment
Penalty
Summary
The facility failed to ensure residents’ rights to informed consent for treatment were protected for two residents who had significant cognitive impairment. One resident with Parkinson’s disease and a Brief Interview for Mental Status (BIMS) score of 5, and another resident with unspecified dementia, aphasia, and a BIMS score of 2, were referred for and received brain mapping/neurofeedback treatment provided by a third-party vendor. The Administrator stated that the third-party provider was responsible for obtaining informed consent from the residents’ responsible parties and that the facility’s practice was to verify this by reviewing a copy of the consent and filing it in the residents’ medical records. During interviews and record reviews, the Administrator acknowledged that a copy of the informed consent for brain mapping/neurofeedback was not present in one resident’s medical record and that she had to request the informed consent for the other resident from the provider on the day of the survey. Additionally, the responsible party for one resident reported not being aware that the resident had been referred for brain mapping/neurofeedback, first learning of the treatment only after requesting a physician order summary, and stated that no consent had been given and the treatment had not been explained. The facility’s own informed consent policy required that residents or their surrogates receive material information in advance, consent to or refuse treatment or experimental research, and participate in care planning, and that facility staff verify that informed consent had been obtained, which did not occur in these cases.
Lack of Care Planning and Coordination for Brain Mapping/Neurofeedback Therapy
Penalty
Summary
The facility failed to provide treatment and care according to physician orders and residents’ needs for two residents who received brain mapping/neurofeedback therapy. One resident with Parkinson’s disease and severe cognitive impairment and another resident with unspecified dementia, aphasia, and severe cognitive impairment were referred by the MD for brain mapping/neurofeedback due to altered mental status. The MD acknowledged that this therapy was not a standard treatment for Parkinson’s disease or dementia but believed it might be beneficial, and later discontinued it after several weeks when no improvement was observed. Physician orders for both residents specified QEEG brain mapping initially and after every fifth neurofeedback session, with neurofeedback therapy 2–3 times per week for 20–40 sessions and re-evaluation for continuance based on therapeutic appropriateness and patient response. Treatment records showed that one resident received therapy from March through October and the other from March through May. The brain mapping/neurofeedback services were provided in the facility by a third-party provider. During surveyor interviews and record reviews, the Administrator confirmed that there were no nursing care plans addressing brain mapping/neurofeedback for either resident. The DSD/LVN reported that the provider did not give after-treatment care instructions for these therapies and that visit notes were not provided immediately, with uncertainty about when they were received by the facility. Despite the provider’s visit notes indicating that the plan of care was coordinated with the primary care team and nursing staff, and that counseling was provided to staff regarding adequate hydration and nutrition in conjunction with neurofeedback, the facility lacked corresponding nursing care plans and documented after-treatment care. The Administrator also reported that one resident’s responsible party requested discontinuation of the therapy due to lack of improvement and stated they had not given consent for the treatment.
Failure to Follow Enhanced Barrier Precautions During G-Tube Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its Enhanced Barrier Precautions (EBP) program for a resident requiring these precautions due to an indwelling gastrostomy tube (G-tube). The resident was admitted with multiple diagnoses including encounter for attention to gastrostomy, and had a Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) score of 02, indicating severe cognitive impairment. The resident’s physician orders included an enteral feeding regimen with water flushes via PEG tube every three hours and specified the use of Enhanced Barrier Precautions during high-contact care each shift due to the G-tube. The resident’s care plan also documented that Enhanced Barrier Precautions were required during high-contact care activities because of the G-tube indwelling device. During observation, a Licensed Vocational Nurse (LVN) entered the resident’s room to perform a water flush through the G-tube and, together with a family member, repositioned the resident in bed. The LVN did not don a gown while performing these high-contact care activities, despite a sign posted outside the room indicating Enhanced Barrier Precautions and the LVN’s own acknowledgment that the resident was on EBP for the presence of a G-tube. The facility’s written EBP policy states that EBPs are used to prevent the spread of multidrug-resistant organisms and require targeted gown and glove use during high-contact resident care activities, including device care or use such as feeding tubes. The LVN confirmed that she did not put on a gown when flushing the G-tube, demonstrating noncompliance with both the resident’s orders and the facility’s EBP policy.
Failure to Employ Full-Time Dietitian and Director of Food and Nutrition Services
Penalty
Summary
The facility failed to meet state requirements for employing a full-time registered dietitian (RD) or a full-time director of food and nutrition services (DS). The DS, who was responsible for dietary staff training and competency checks, worked only 20 hours a week at the facility and an additional 20 hours at a sister facility. The RD worked part-time, between 8-16 hours a week. This staffing deficiency was confirmed during interviews with the DS, RD, and the Administrator, who acknowledged the lack of full-time staff in these critical roles. This failure had the potential to impact the food and nutrition services for all 26 residents in the facility.
Food Storage and Preparation Deficiencies
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food service safety. During an initial tour of the kitchen, it was observed that a hand washing sink was located right next to a coffee machine and beverage dispenser, raising concerns about water splashes. Multiple food items in the refrigerator and walk-in refrigerator were found opened with no use-by dates. The dishwashing machine was not operational, and the facility was using a three-compartment sink for dishwashing, but the water in the sink had a brownish discoloration, and the water temperature and sanitizer test strip results were not recorded every 30 minutes as required. Additionally, the ice machine had a brownish white hard, sticky substance on the outside, and three kitchen air vents and a fly trap had excessive blackish dust. The floor drains and air gap by the ice machine and walk-in refrigerator had brownish black discoloration. A dietary aide was observed picking up trash from the kitchen floor and then distributing water from a beverage cart without washing hands in between tasks. The Dietary Services Supervisor (DS) and Registered Dietician (RD) acknowledged the issues during the observations. The DS stated that he was not concerned about water splashes from the hand washing sink as long as the coffee dispenser was covered. The RD confirmed that the water temperature in the three-compartment sink needs to be checked every 30 minutes, which was not being done. The Maintenance Supervisor (MS) admitted to missing the cleaning of the kitchen ceiling vents and stated that the air gaps area would be added to their maintenance cleaning schedule. The RD also noted possible infection control concerns related to the coffee and beverage dispenser being next to the sink. The facility's policy and procedure on sanitation indicated that the Food and Nutrition Services (FNS) director is responsible for instructing employees in sanitation fundamentals and maintaining equipment, with assistance from the Maintenance Department as necessary.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure safe medication storage and accurate labeling of medications. Specifically, Resident 22's medication card for Colchicine did not match the physician's order. The medication card indicated to give Colchicine one tablet two times a day, while the physician's order specified one tablet once a day. This discrepancy was acknowledged by LVN 1 during a medication administration observation and further confirmed during an interview with RN 1. The facility's policy requires nursing staff to inform the pharmacy of any changes in physician's orders, which was not followed in this case, leading to a risk of medication administration error and potential adverse effects for Resident 22, who was admitted with a diagnosis of gout. Additionally, during an inspection of medication cart 1, three and one-half loose tablets were found, which were not in a labeled container. RN 1 was unable to identify the loose tablets and stated that they should not have been in the medication cart and should have been disposed of. The facility's policy mandates that medications be stored in an orderly manner to prevent mixing medications of several residents, which was not adhered to in this instance. This failure had the potential for medication error and contamination.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to dispose of garbage and contain refuse properly when a dumpster located by the side of the facility was observed to be full of trash bags and not closed or covered. This observation was made on 3/19/24 at 8:39 a.m. with the Dietary Services Supervisor (DS), who confirmed that the dumpster was supposed to be closed. Additionally, during an interview at 09:01 a.m. on the same day with the Maintenance Director (MS) and Administrator (Admin), MS stated that the dumpster was to be closed when not in use. A review of the facility's policy and procedure, titled 'Medical Waste, Handling of,' revised September 2010, indicated that the outside compactor/dumpster must be locked when not in use and at night.
Failure to Include Resident and Representative in Hospice Plan of Care
Penalty
Summary
The facility failed to follow a written hospice agreement that included joint responsibilities to develop and implement a plan of care for a resident admitted into the hospice program. The resident and their representative were not included or participated in the development and implementation of the hospice plan of care. This failure was identified through interviews and record reviews, which revealed that the resident's representative had concerns about the lack of communication regarding the resident's care. The only care planning conference the representative participated in was before the resident was admitted to hospice care. The review of the resident's clinical records indicated that the hospice plan of care was initiated without the involvement of the resident or their representative. The Social Services Director admitted that no care planning conference was arranged with the resident, their representative, and the hospice provider. The facility's policy required the Social Services Director to coordinate with facility staff and the hospice provider, but this was not done. The hospice services agreement stipulated that the hospice and facility staff should jointly develop and agree upon the patient's plan of care, which did not occur in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Livermore
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avondale Villa Post-acute | 0 mi | ★★★★★ | 1 | 0 |
| The Vineyards Healthcare Center | 0.2 mi | ★★★★★ | 2 | 0 |
| Creekview Skilled Nursing | 4.1 mi | ★★★★★ | 0 | 0 |
| Pleasanton Nursing And Rehabilitation Center | 5 mi | ★★★★★ | 11 | 0 |
| The Reutlinger Community | 10.9 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.